East Midlands Clinical Senate Reportemsenate.nhs.uk/downloads/documents/clinical senate... · East Midlands Clinical Senate Report 11 Physical activity and exercise medicine 3 Background

East Midlands Clinical Senate ReportPhysical activity and exercise medicine

Report byProfessor Mark E Batt Consultant Sport & Exercise Medicine

East Midlands Clinical Senate Council member

Suzanne HorobinEast Midlands Strategic Clinical Networks and Senate

3East Midlands Clinical Senate Report Physical activity and exercise medicine

1 Executive summary � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5

2 Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6

3 Background � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8

3.1 Facts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

3.2 East Midlands Research institutions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12

3.3 Physical activity in the treatment of chronic disease � � � � � � � � � � � � � � � � � � � 15

4 The case for change in the East Midlands � � � � � � � � � � � � � � � � � � � � � � � � � � � � 17

4.1 East Midlands physical activity needs � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 17

4�1�1 Maintaining good health � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 18

4�1�2 Risk reduction, rehabilitation and treatment � � � � � � � � � � � � � � � � � � � � � � � 23

4.2 RCP Commissioning Guidance � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 26

5 Recommendations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28

5.1 The Clinical Senate is supportive of the following initiatives � � � � � � � � � � 28

5�1�1 Existing NICE guidelines � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28

5�1�2 Return on investment tools � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 29

5�1�3 Public Health England - Everybody active, every day � � � � � � � � � � � � � � � � 29

5�1�4 Third sector provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 30

5.2 The Clinical Senate recommends the following be developed � � � � � � � � 31

5�2�1 Lie less, sit less� Do more, more often (primary, secondary and tertiary

prevention) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 31

5�2�2 Support the development of a network for existing East Midlands groups

(enhanced secondary and tertiary prevention) � � � � � � � � � � � � � � � � � � � � � � 31

5�2�3 Making every contact count: (primary, secondary and tertiary prevention)

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 32

5�2�4 Signposting / messaging: physical activity on referral / sport & exercise

medicine � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33

5�2�5 Training curricula � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 34

5�2�6 Evidence the benefits / return on investment � � � � � � � � � � � � � � � � � � � � � � � 34

5�2�7 Physical activity as a treatment for mental health � � � � � � � � � � � � � � � � � � � 36

5�2�8 Thinking differently � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37

Content


Content

5.3 The Clinical Senate recommends the following be actively commissioned -

across health and social care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37

5�3�1 Education programme: Everybody active, every day: (primary, secondary

and tertiary prevention) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37

5�3�2 Healthy workplace � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 38

5�3�3 Review of existing service provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 38

5�3�4 Exercise medicine: (enhanced secondary and tertiary prevention) � � � � 40

6 Appendices � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41

6.1 Chief Medical Officer Physical Activity Guideline � � � � � � � � � � � � � � � � � � � � � � 41

6.2 Who is currently responsible for what? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 43

6.3 Examples of existing provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 45

6�3�1 Leicestershire and Rutland � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 45

6�3�2 Northamptonshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49

6�3�3 Derbyshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49

6�3�4 Nottinghamshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49

7 Referenced evidence base � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 50

7.1 Literature review � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 50

7.2 Collation and summary of existing professional and national guidelines

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 51

8 Acknowledgements � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53


This report by the East Midlands Clinical Senate provides

background information, a case for change and

recommendations to encourage more people to be more

active more of the time�

The focus of the report is physical activity and the benefits

to be obtained through its use in prevention of ill health, in

risk reduction and as an active treatment�

The Council recommends the support of a number

of existing national initiatives, the development of

regional programmes and networks and specifically the

commissioning of:

• Educationprogrammeforhealthcareprofessionals

• Healthyworkplaceinterventions

• Reviewofexistingserviceprovision

• Exercisemedicineservices

Clinical commissioners are encouraged to work in

collaboration with Public Health colleagues to address the

gaps in the current system�

It is suggested that this report be read in conjunction

with Public Health England’s Everybody active, every day�

Specifically, this report provides a framework for an East

Midlands response�

https://www�gov�uk/government/publications/everybody-

active-every-day-a-framework-to-embed-physical-activity-

into-daily-life

1 Executive summary

https://www.gov.uk/government/publications/everybody-active-every-day-a-framework-to-embed-physical-activity-into-daily-life




2 Definitions

Physical Activity: body movement that expends energy

and raises the heart rate�

Inactivity: less than 30 minutes physical activity a week�

Sedentary: time spent in low-energy postures, eg, sitting or

lying�

Sport and exercise medicine (SEM): is a new speciality of

medicine involving the medical care of injury and illness in

sport and exercise�

In primary care, SEM physicians can:

• Workwithprimarycareteamsandpublichealth

to support effective physical activity prescription,

including providing education for the primary care

team so that consistent, evidence based and effective

physical activity interventions are provided�

• Provideexpertiseforpatientsrequiringspecialist

input; for example those identified as ‘high risk’ due

to medical conditions and co-morbidity and those

requiringmoreintensebehaviouralinterventions.

• Providelocallybasedmusculoskeletalservices,bringing

a range of additional skills such as leadership, triage,

rapid access to ultrasound scans, evidence based

injection therapies, specialised back pain services and

chronic pain services etc�


2 Definitions

In secondary care, SEM physicians can:

• Restructureandmoderniseexistingrehabilitation

services so they are patient-centred, evidence-based

and inclusive of all chronic disease areas effectively

treated by exercise�

• Establishmultidisciplinaryteamstoprovideasingle

pointofreferralforpatientsrequiringspecialisthelp

to overcome their medical, social or cultural barriers to

exercise�

• EstablishSEMledclinicstoworkalongsideexisting

orthopaedic, physiotherapy and emergency

department services in identifying, treating and

rehabilitating acute and chronic musculoskeletal

disorderswhichdonotrequiresurgery.

SEM physicians can support commissioners in specifying

services for people who are unwell including pathways for

personalising exercise interventions amongst those who

do not feel they are able to exercise (anxious, overweight,

musculoskeletal pain etc�)


3 Background

This report should be read in conjunction with the Public

Health England publication Everybody active, every day - An

evidence-based approach to physical activity.

https://www�gov�uk/government/publications/everybody-

active-every-day-a-framework-to-embed-physical-activity-

into-daily-life

Physical inactivity poses a serious and growing threat to

our society - it is a pan-societal issue damaging our health,

economy and environment� Levels of physical activity are

declining and we need to act� Other high-income countries

like Finland, the Netherlands and Germany have shown that

the situation can be changed�

The All Party Commission on Physical Activity report Tackling

Physical Inactivity - A Coordinated Approach (2014) offered

five recommendations:

1. A national action plan

2. Getting the message out

3. Designing physical activity back into our everyday lives

4. Making physical activity a lifelong habit

5. Proving success

These recommendations have been followed by the

Everybody active, every day report which provides the

background and impetus for this report�


3 Background

3.1 Facts

The Public Health report Everybody active, every day provides the following graphical

summary of the current levels of physical inactivity�

Everybody active, every day

5

64% of trips are made by car 22% are made on foot2% are made by bike

19% of men and 26% of women are

'physically inactive'

33% of men are not active enough for

good health

21% of boys and 16% of girls aged 5-15 achieve

recommended levels of physical activity

47% of boys and 49% of girls in the lowest economic group are

'inactive' compared to 26% and 35% in the highest

Walking trips decreased by 30%

between 1995 and 2013

45% of women are not active enough for

good health

23% of girls aged 5-7 meet the

recommended levels of daily physical activity, by ages 13-15 only 8% do

18% of disabled adults regularly take

part in sport compared to 39% of non-disabled

adults

The extent of the problem

Data sources: Health Survey for England 2012 (HSE); Active People Survey 8, April 2013-April 2014 (APS); National Travel Survey 2013 (NTS)

We want to engage with professionals, providers and commissioners in health, social care, transportation, planning, education, sport and leisure, the voluntary, community and cultural sectors as well as public and private employers to make the case for more – much more – physical activity, every day.


3 Background

• 70% of NHS spend is on long-term conditions� As long

agoas2002theWanlessreport Securing our future

health (2002) (and later - Securing health for the whole

population (2004)) confirmed that with no increased

investment in chronic disease prevention our healthcare

economy is not sustainable in the long-term�

• Onaverage,aninactivepersonspends38%moredays

in hospital than an active person, and utilises 5�5%

more GP visits, 13% more specialist services and 12%

more nurse visits than an active individual�

• TheUKfacesanepidemicofphysicalinactivity-we

have dramatically ‘engineered’ movement out of our

lives, to the extent that humans have never been so

inactive� Only 39% of men and 29% of women in the

UKmeetminimumphysicalactivityrecommendations

when measured subjectively and 5% when measured

objectively�

• Thepopulationdoesnotunderstandtheconsequences

of physical inactivity - low fitness kills more people

than smoking, diabetes and hypertension combined�

• Healthylifeexpectancyisincreasedbyphysicalactivity

• Onlyonethirdofthepopulationtakeenoughphysical

activity to maintain good health�

• Thereexistsasignificantgapinperceptionandreality

regarding how active we are�

• Physicalinactivitycontributesto1:10prematuredeaths

(37,000 in England annually): a greater cause of death

intheUKcomparedtoUSA(moreobesity),Franceand

The Netherlands�

• Dietandphysicalinactivityaccountedfor14.3%(95%

UI12.8—15.9)ofUKdisabilityadjustedlifeyearsin

2010�


3 Background

• Theeffectsofphysicalactivityarelargelyindependent

of obesity or weight loss� In other words, the benefits

of physical activity are achieved even in the absence of

weight loss; hence the advice that it is better to be ‘fat

and fit’ than ‘lean and unfit’�

• Ifthepracticalproblemsofchangingthebehaviourof

the population could be addressed, the benefits to the

NHS could be very significant:

- 30% to 50% reductions of risk in the

development of common chronic conditions,

including cancer, ischaemic heart disease, obesity

and diabetes, dementia and depression�

- Significant improvements in the efficacy of

treatment of those same chronic conditions

- Improved outcomes, patient satisfaction and

reduced costs (many fewer GP and orthopaedic

presentations) for musculoskeletal injuries�

• AMacmillanCancerSupportpublicationMove More

states that there are two million cancer survivors in the

UKandestimatesthat1.6millionarenotphysically

active to recommended levels

• InorderforthepopulationoftheEastMidlandsto

maintain good health 20 million hours of physical

activityperweekarerequired.

Sedentary behaviour is emerging as an important target in

the prevention and treatment of chronic disease� Although

often used interchangeably, “sedentary behaviour” and

“inactivity” are different constructs and need different

solutions�


3 Background

Sedentary time refers to all non-exercise sitting time and

inactivity refers to those who fail to meet the physical

activity guidelines� Hence it is possible to be active, but still

have high sedentary behaviour�

A journal article for Diabetes Research and Clinical Practice

(2011) Stand up for your health: Is it time to rethink the

physical activity paradigm? confirms that although the

importance of physical activity in the prevention and

treatment of chronic disease is clear and must remain, there

is increasing evidence that it will not offset the deleterious

effects associated with sedentary behaviour� Strategies

based on simply sitting less and standing more are therefore

expected to revolutionise the health promotion field in

coming years�

3.2 East Midlands Research institutionsThe East Midlands could be heralded as the national

exemplar for attracting funding in the area of physical

activity, sedentary behaviour and health, particularly from

the National Institute for Health Research (NIHR)�

Wehaveinourregionaresourcewithwhichtotranslate

and commission evidence-based physical activity-based

interventions and programmes� The government has

invested substantial resources into developing and

evaluating physical activity-based therapies locally� This

reportposesthequestion-whyaren’ttheseservicesmore

commonly commissioned?


3 Background

Some of the research infrastructure is listed below:

• NIHRLeicester-LoughboroughDiet,Lifestyleand

PhysicalActivityBiomedicalResearchUnit

- Focused on using experimental research to

extend the range of evidence-based physical

activity-based therapies

- TheonlyBRUfundednationallythathasa

specific focus on physical activity

- £4�5 million in funding over five years

- DESMOND (Diabetes Education and Self

Management for Ongoing and Newly

Diagnosed):Walkingawayfromdiabetes

http://www�desmond-project�org�uk/

walkingaway-280�html

• NIHREastMidlandsCollaborationforLeadershipin

Applied Health Research and Care (EM-CLAHRC)

- Focused on translating evidence-based medicine

into routine care

- Strong focus on lifestyle, including physical

activity

- £10 million in direct funding and £10 million in

matched funding over five years

- Specific interventions to empower individuals

focusing on chronic obstructive pulmonary

disease (COPD) self-management strategies and

post-cardiac rehabilitation options

- The use of technology to support self-

management in people with chronic disease�


3 Background

• NationalCentreforSportandExerciseMedicineinthe

East Midlands (NCSEM-EM)

- Part of the Olympic legacy in conjunction with

sites in London and Sheffield

- Remit for extending the SEM profession into the

prevention and treatment of chronic disease

- £10 million for a state of the art facility on

LoughboroughUniversitycampus:opens2015.

• LeicesterDiabetesCentre

- One of the largest diabetes research centres in

Europe

- Strong track record in developing and evaluating

lifestyle intervention in the prevention and

management of type 2 diabetes and other

chronic diseases

- Includes a specialist group of physical activity and

sedentary behaviour researchers

- Developed the Leicester Prevention Pathway that

includes a range of fully evaluated resources

for: 1) identifying those within primary care that

have a high risk of type 2 diabetes, 2) confirming

risk status (blood test), 3) information leaflet

including physical activity, and 4) referral onto a

suite of prevention programmes that are based

on the promotion of increased physical activity

and other lifestyle behaviours, including the

WalkingAwayfromType2DiabetesProgramme.

Partsofthepathway,includingWalkingAway,

have been widely commissioned nationally�

However local provision has been patchy and

sporadic�


3 Background

3.3 Physical activity in the treatment of

chronic disease

TheFacultyofSportandExerciseMedicineintheUK’s

recent report ‘A Fresh Approach in Practice’ (2013) states

that increasing activity levels can inexpensively treat chronic

disease, musculoskeletal conditions and sports injuries�

This is in addition to the decrease in chronic disease risk by

30-50%, prevention of co-morbidity and aiding recovery,

functionandimprovingqualityoflifeinthosewhodosuffer

from chronic disease�

The report shares a number of examples of services which

have delivered a return on investment� A community

musculoskeletalserviceinNewcastleWestreducedsecondary

care orthopaedic referrals by 40%, improved the efficiency

of the orthopaedic outpatient conversion to surgery to 82%,

and lowered rheumatology referrals by 8% and neurosurgery

by 44%� It also delivered a reduction in cost of £42k�

There exists a commonality of risk factors for chronic

diseases (1:2 cancer diagnoses have 2+ other chronic

diseases), thus treating these conditions in isolation is

nonsensical�

It is envisaged that savings may be found using physical

activity to treat chronic diseases� (Table 1)


3 Background

Table 1 - The effect of physical activity on chronic diseases - Faculty for Sport and Exercise Medicine

Long term physical activity adherence for those with chronic disease remains low�

Compliance can be improved by specific behavioural interventions, focusing on self-efficacy

and sensitivity to the complex and individual social, medical and cultural barriers which

preclude people with chronic disease from long term physical activity�

In their report Everybody active, every day, Public Health England outline four domains

foractiontocreatetherequiredculturalchangethatwillachievethesimpleoutcomeof

everyone being more active�

8

Physical activity in the treatment of disease

Section 2 of this document deals with the effect of exercise on the treatment of chronicdisease. The list of diseases effectively managed with physical activity continues to grow.There is Level 1 evidence for the effectiveness of physical activity in the management ofmost chronic disease areas and consequently exercise is now included in multiplespecialist treatment guidelines.

In primary care, GPs are likely to be asked to screen for physical inactivity usingquestionnaires and will then be asked to identify high risk patients. There is currently noroutine education or support for GPs, or other members of the primary care team, onphysical activity prescription for those identified by this screening procedure as high risk.

Ischaemic heart disease 35-40% reduction in risk of event

COPD Improvement in aerobic fitness, quality of life,symptoms of dyspnoea, CV risk factors

Breast cancer 50% reduction RR of breast cancer death

Bowel cancer 50% reduction in bowel cancer death Improvementof tolerance of cancer treatment

Cerebrovascular disease Improvement of aerobic capacity,sensorimotor function and CV risk factors

Diabetes 42% reduction in diabetes related mortality32% reduction in diabetes related complications

Impaired glucose tolerance 42% reduction in risk of developing diabetes

Hypertension Reduce systolic BP by 7.4mmHg anddiastolic BP by 5.8mmHg

Depression/anxiety disorders Effect as good as standard pharmacologicaltreatments for moderate depression

Rheumatoid arthritis Improved aerobic fitness, diseaseactivity, function and QoL

Osteoarthritis Improved aerobic capacity, reduce fatigue andpain. Improve muscle strength and function

Osteoporosis Reduction in risk of falls. Maintenance of BMDin men and postmenopausal women

Pregnancy Reduce risk of pregnancy induced diabetes

Chronic disease Effect of exercise therapy


The evidence for physical activity in the prevention and

treatment of chronic disease has been building over the past

few years, and is encapsulated by the Public Health England

report Everybody active, every day.

This report from the East Midlands Clinical Senate Council

is a call to action for commissioners in the East Midlands to

contributetotheoverallefforttoaffecttherequiredchange

in our region�

4.1 East Midlands physical activity needsTheUKActivereportTurning the tide of inactivity

www�ukactive�com/turningthetide confirms that:

• TheEastMidlandshasoneofthelowestproportional

public health spends on physical inactivity (1�8%)

compared to the national average (2�4%)

• Largeurbanareas,suchasLeicesterandNottingham,

have higher than average levels of adult physical

inactivity (33-34%)

• Physicalinactivityislowerinlessdenselypopulated,

affluent areas such as Rutland (24%)

• Theregionhasahigherthanaverageproportion

of green spaces (the proportion of region made up

of green and open spaces) (60%) compared to the

national average (46%)

4 The case for change in the East Midlands



4.1.1 Maintaining good health

Physical activity guidelines for the maintenance of good

health were set out by the four Home Countries Chief

Medical Officers (CMO) in the 2011 report ‘Start Active,

Stay Active’� These guidelines built on the previous advice

through the addition of age specific guidance, and activity

type recommendations� (Appendix 6�1)

It is acknowledged that some groups need relatively more

physical activity to gain benefits for health�

Table 2 below outlines the recommendations and identifies

the total physical activity needed for the maintenance of

good health across the East Midlands population - a total of

19�3 million hours of physical activity per week�

Age

group

East

Midlands

population

Recommended

daily activity

Recommended activity type Total weekly

physical

activity

requirement0-4s 297,485

total

(209,157

between 18

months and

5 years)

180 minutes

active once

walking (proxy

from 18

months)

Light activity such as standing

up, moving around, rolling

and playing, as well as more

energetic activity like skipping,

hopping, running and jumping�

Active play, such as using a

climbing frame, riding a bike,

playing in water, chasing games

and ball games, is the best

way for this age group to be

physically active�

4�39 million

hours



Age

group

East

Midlands

population

Recommended

daily activity


physical

activity

requirement5-18s 788,122 Moderate to

vigorous activity

for 60 minutes

up to several

hours per day

Vigorous intensity including

bone and muscle strengthening

on at least 3 days / week�

Examples of energetic activities

suitable for most children who

can walk on their own include:

• active play (such as hide and

seek and stuck in the mud)

• fastwalking

• ridingabike

• dancing

• swimming

• climbing

• skippingrope

• gymnastics

Energetic activity for children will

make kids “huff and puff” and

can include organised activities,

like dance and gymnastics� Any

sort of active play will usually

include bursts of energetic

activity�

5�52 million

hours

19-64s 2,901,665 At least 150

minutes per

week moderate

intensity (or

75 minutes

vigorous) per

week

Bone and muscle strengthening

on at least 2 days / week�

7�25 million

hours



Age

group

East

Midlands

population

Recommended

daily activity


physical

activity

requirement65+ 867,159 At least 150

minutes per

week moderate

intensity (or

75 minutes

vigorous) per

week

Bone and muscle strengthening

on at least 2 days /week, plus

balance exercise for those at risk

of falls�

2�17 million

hours

TOTAL 19.3 million

hours per

week

Table 2:PhysicalactivityrequirementsforthemaintenanceofgoodhealthfortheEastMidlands

Examplesofactivitiesthatrequiremoderateeffortformost

people include:

• walkingfast

• wateraerobics

• ridingabikeonlevelgroundorwithfewhills

• ballroomandlinedancing

• doublestennis

• pushingalawnmower

• hiking

• skateboarding

• canoeing

• rollerblading

• volleyball

• basketball



Moderate-intensity activity raises the heart rate and results

in breathing faster and feeling warmer� One way to tell if

activity is at the level of moderate intensity is if it is possible

to still talk but not sing the words to a song�

Examplesofactivitiesthatrequirevigorouseffortformost

people include:

• joggingorrunning

• aerobics

• swimmingfast

• ridingabikefastoronhills

• playingsinglestennis

• playingfootball

• hikinguphill

• energeticdancing

• martialarts

Vigorous-intensity aerobic activity means you’re breathing

hardandfast,andyourheartratehasgoneupquiteabit.If

you’re working at this level, you won’t be able to say more

than a few words without pausing for a breath�

Sport England data (Active People Survey 8 - 2014) shows

that less than a third of adults aged 16 and over are

achieving an average of 90 minutes of moderate intensity

physical activity per week (12 x 30 minutes moderate

intensity physical activity over the past 4 weeks) within the

East Midlands, a level well below the 150 minute per week

recommended for the maintenance of good health�



Local Authority % Achieving 3 x 30 mins

moderate activity per

week

CCGs

Rutland 30�7% East Leicestershire & Rutland MiltonKeynes 28�7% MiltonKeynesNorthamptonshire 27�61% NeneCorbyLeicestershire County 27�6% WestLeicestershireEast

Leicestershire & RutlandNottinghamshire County 27�4% Mansfield & AshfieldNewark & SherwoodNottinghamshire ErewashRushcliffeNottingham North and EastNottinghamWestDerbyshire County 25�7% South DerbyshireNorth DerbyshireErewashHardwickLincolnshire County 25�0% South LincolnshireSouthWestLincolnshireLincolnshire EastLincolnshireWestNorth LincolnshireNottingham City 24�6% Nottingham CityDerby City 22�6% South DerbyshireLeicester City 19�7% Leicester City

Table 3: The percentage of the adult (age 16 and over) population in a local area who participate in sport and

active recreation, at moderate intensity, for at least 30 minutes on at least 12 days out of the last 4 weeks

(equivalentto30minuteson3ormoredaysaweek).SportEnglandAPS8.



CASESTUDY

An exercise referral outreach

class takes place weekly in

a Leicestershire village hall�

Classes are run for GP referral

patients and for cardiac /

pulmonary rehabilitation

referral patients�

One of the patients attending

is living with cancer� She is

receiving palliative treatment�

She has been attending the

GP referral outreach class for

around 10 months when she

feels well enough and receives

chemotherapy treatment every

three weeks�

She was told by her doctor

that she needed to take

up some form of exercise

and was told that any

exercise which would help

to strengthen her bones

would help her condition�

The sessions provided are

at the right level for her to

participate and they help to

manage her condition� Her

consultant has confirmed that

her condition is stable�

The outreach class has helped

this lady to take up some

form of structured activity

which has in turn helped her

to undertake the necessary

exercise in order to strengthen

her bones as recommended by

her doctor�

4.1.2 Risk reduction, rehabilitation and

treatment

It is important to note that the Chief Medical Officer

recommendationsfocusonthephysicalactivityrequirements

for the maintenance of good health� (Appendix 6�1)

Physical activity can also be used to reduce risk of certain

conditions, for rehabilitation following the effects of injury

or acute health events (such as myocardial infaction or a

severe chronic obstructive pulmonary disease related event)

or as treatment to reduce or alleviate symptoms�

In these instances there may be a need for more specific

exercise prescription to ensure the achievement of clinical

benefit,withthefrequency,intensity,durationandtype

of exercise varying from and potentially exceeding the

recommended levels for the maintenance of good health�

Table 4 highlights the potential for health gain from physical

activity, identifying the GP registered prevalence (QOF

2012/13 data) for those conditions which are amenable

to prevention and/or treatment with physical activity and

exercise�



Conditions amenable to

prevention or treatment

with physical activity/

exercise

QOF register prevalence

for Midlands and East

region

Estimated number of

affected individuals for

the East Midlands

Asthma 6�2% 300,974Atrial Fibrillation 1�6% 77,671Cancer 2�0% 97,088Coronary Heart Disease 3�4% 165,050ChronicKidneyDisease(18+) 4�6% 176,146Chronic Obstructive

Pulmonary Disease

1�7% 82,525

Cardiovascular Disease 2�3% 111,652Dementia 0�6% 29,127Depression (18+) 6�0% 229,755Diabetes (17+) 6�3% 244,976Heart Failure 0�8% 38,835Hypertension 14�3% 694,182Hypothyroidism 3�4% 165,050Obesity (16+) 11�2% 442,107Osteoporosis (50+) 0�2% 3,555Peripheral Artery Disease 0�6% 29,127Stroke/TIA 1�7% 82,525

Table 4 - GP registered prevalence (QOF 2012/13 data) for those conditions which are amenable to prevention

and/or treatment with physical activity and exercise

A key issue is getting a population to be more physically

active, either as a preventative measure (wellness) or as a

part of the treatment of chronic disease or musculoskeletal

injury� The challenge is to persuade the sedentary, unfit and

unwell to change their behaviour� This behavioural change

requiresaninvestmentoftimeandtrainingtocreatethe

expertise to provide advice, encouragement and selective

long term monitoring�



CASESTUDY

Agnes Graham is known

as Nessa� Nessa is visually

impaired, which means that

she has absolutely no vision at

all� She joined a Leicestershire

exercise referral scheme in

March 2014 and has been

attending the gym twice a

week ever since then� Despite

her impairment, Nessa walks

with her guide dog which in

itself takes determination and

courage�

Through sheer hard work,

Nessa has managed to

increase her fitness levels and

lose over a stone in weight�

Attending the gym has made

a significant difference to

Nessa’s life and she has made

new friends� Nessa is a total

inspiration to everyone!

She recently won an Exercise

Referral and Healthy Heart

Scheme award at the

Leicestershire and Rutland

awards evening�

Whilstthisreportdoesnotseektomapcurrentprovision

across the whole of the East Midlands we would like to

highlightthatthereisinequityofprovision.

A report is expected from Health Education East Midlands

working with the British Heart Foundation and Oxford

Universitythatwilldescribecurrentexerciserehabilitation

service provision across the country�

Existing commissioned services are often ‘disease-based’�

For example, exercise rehabilitation services for cardiac,

pulmonary and renal diseases� A number of third sector

and private providers also offer silo-based physical activity

programmes, both commissioned and charitably funded�

There is an opportunity for alignment of physical activity

messaging and symptom based service delivery where it is

clinically appropriate to do so�



4.2 RCP Commissioning GuidanceThe Royal College of Physicians (RCP) advises that sport

and exercise medicine is not simply a specialty for the

management of elite athletes’ medical conditions but is

central to the promotion of physical activity as a means

of disease prevention, to enhance well-being and in the

management of disease�

Spanning primary, secondary and tertiary care, the role of a

sport and exercise consultant includes leading or supporting

multidisciplinary teams using expertise in physiotherapy,

nutrition, psychology, musculoskeletal and general medicine�

The work may involve promoting physical activity in special

groups such as pregnant women, those with diabetes,

cardiovascular disease and the overweight and obese (both

adults and children), as well as managing musculoskeletal

injuries, and working with sports men and women on all

aspects of performance, injury and illness minimisation�

Workingwithcolleaguesinpublichealth,theDepartment

of Health and the NHS to implement policies that enhance

health, sport and exercise medicine has a key role in

developing new approaches to healthcare and promoting

population health�



RCP advice on key points to consider when commissioning

sport and exercise medicine services:

• Globalphysicalinactivitycauses9%ofpremature

deaths, 5�3 million of the 57 million deaths that

occurred in 2008�

• Maintainingphysicalactivityatrecommendedlevels

canequatetothree-fouryearsinadditionallife

expectancy with risk reductions of the order of 20-

40% for over 22 non-communicable diseases�

• TheNHScouldmakesubstantialsavingsbytargeting

promotion of physical activity as part of chronic disease

models�

• Currentcostsofprovidinghealthcarecoverfor

a physically inactive ageing population are not

sustainable�

• TheNHSneedstoinvestproportionatelytotheburden

of physical inactivity to develop sustainable prevention

and treatment models for chronic disease�

• Sportandexercisemedicineconsultantsaretrainedin

providing evidence-based and effective physical activity

interventions for primary and secondary prevention of

chronic disease�

• Sportandexercisemedicineconsultantsofferunique

and specific skills in the diagnosis, treatment and

rehabilitation of musculoskeletal, soft-tissue and sport

injuries�

• Sportandexercisemedicineservicesmaybesituated

in both community and secondary care settings, and

tailored to meet local pressures and needs�

https://www�rcplondon�ac�uk/projects/clinical-

commissioning-hub/commissioning-sport-exercise-medicine-

services

https://www.rcplondon.ac.uk/projects/clinical-commissioning-hub/commissioning-sport-exercise-medicine-services




The East Midlands Clinical Senate is supportive of physical

activity to enhance health and recognises the need for pan-

societal solutions� The provision of physical activity in the

prevention and treatment of ill-health is recognized as not

wholly a healthcare responsibility�

In addition to being supportive of a number of

initiatives already underway, this report makes specific

recommendations to commissioners relating to actions to

improve the availability of physical activity as a preventative

and a treatment measure�

These recommendations are based on an understanding of

the role of physical activity in primary, secondary and tertiary

prevention strategies for chronic diseases linked to physical

inactivity�

5.1 The Clinical Senate is supportive of the following

initiatives

5.1.1 Existing NICE guidelines

PH6 2007 Behaviour change: the principles for effective interventions

PH8 2008 Physical activity and the environment

PH13 2008 Promoting physical activity in the workplace

PH17 2009 Promoting physical activity for children and young people

PH41 2012 Walkingandcycling:localmeasurestopromotewalkingandcyclingas

forms of travel or recreation

PH42 2012 Obesity: working with local communities

PH44 2013 Physical activity: brief advice for adults in primary care

PH49 2014 Behaviour change: inidividual approaches

PH54 2014 Exercise referral schemes to promote physical activity

5 Recommendations


5 Recommendations

5.1.2 Return on investment tools

Public Health England has published a Guide to online tools

for valuing physical activity, sport and obesity programmes

which provides an overview of a number of resources

including:

• PublicHealthEnglandobesityeconomicimpacttool

• WorldHealthOrganisationHealthEconomic

Assessment Tool (HEAT) for walking and cycling

• SportEnglandModelforestimatingtheOutcomesand

Values in the Economics of Sport (MOVES)

• NICEPhysicalactivityreturnoninvestmenttool

• SportEnglandEconomicImpactofSport-LocalModel

• PHE/SustransHealthImpactofPhysicalInactivity(HIPI)

tool

http://www�noo�org�uk/gsf�php5?f=313207&fv=20622

5.1.3 Public Health England - Everybody active,

every day

Public Health England publishes their physical activity

implementation framework in October 2014� Senate

Council members have supported expert groups since

August 2014 to consider the detail of how this will be

rolled out� The Clinical Senate is supportive of the advice

and would welcome an East Midlands wide physical activity

programme�


5 Recommendations

The Clinical Senate Council is supportive of a social

movement for a more active society, creating a network of

trained professionals, all working in an environment more

conducive to physical activity�

5.1.4 Third sector provision

There is an interest within the Richmond Group of charities

(and others) in reviewing existing disease and condition-

based physical activity provision with a view to considering

whether symptom-based provision - such as fatigue,

weakness and breathlessness - would better meet patient

need and be more cost effective�

Alongside charities working to support health are

organisations with a responsibility for green spaces� The

Clinical Senate would be supportive of further discussions

between these two sectors to consider working together to

further enhance provision of services�


5 Recommendations

5.2 The Clinical Senate recommends the

following be developed

5.2.1 Lie less, sit less. Do more, more often

(primary, secondary and tertiary prevention)

An East Midlands wide physical activity awareness

programme is needed to encourage individuals to take

responsibility for appropriate levels of physical activity� Sticky

messages that complement campaigns already in existence

e�g� Change for Life (2009) www�nhs�uk/change4life and

campaignsaimedatallarerequired.

The NICE return on investment tool would suggest that

targeted promotion of messages is more effective at local

level - through schools, primary care lists and health check

programmes�

5.2.2 Support the development of a network

for existing East Midlands groups (enhanced

secondary and tertiary prevention)

In order to support commissioners and providers to

maximise the beneficial outcomes from existing services, it

is proposed that interested groups are brought together to

form an East Midlands network� It is recognised that some

servicesrequirespecialistservices(forexamplestroke).

There are however opportunities for currently silo based

services such as cardiac, pulmonary, renal and cancer to

be reconfigured to provide symptom specific services to

address, for example, fatigue, weakness and reduced

aerobic capacity�


5 Recommendations

There is significant evidence of the efficacy of networks in

achieving change at scale in the current Strategic Clinical

Network supported structures in areas such as cancer and

cardiovascular disease�

5.2.3 Making every contact count: (primary,

secondary and tertiary prevention)

Across the healthcare community, at each patient / client

encounter every health and social care professional should

feelconfidentaboutaskinglifestylequestionsthatinclude

physical activity level� They should be suitably informed to

be able to deliver physical activity advice where appropriate

and signpost supportive services�

The Making Every Contact Count website encourages

conversations based on behaviour change methodologies

(ranging from brief advice, to more advanced behaviour

changetechniques),empoweringhealthierlifestylechoices

and exploring the wider social determinants that influence

allofourhealth.Whilstitdoesnotdealspecificallywith

physical activity, it provides resources to assist individuals

and organisations to deliver their approach� For example,

the Making Every Contact Count self-assessment tool

provides a way to identify and review existing skills in

relation to Prevention and Lifestyle Behaviour Change: A

Competence Framework and plan how to improve those

skills.Ithelpsanswerthequestion“amImakingevery

contact count?”

http://www�makingeverycontactcount�co�uk/


5 Recommendations

5.2.4 Signposting / messaging: physical

activity on referral / sport & exercise medicine

It is recognised that the availability of activity on referral

schemes, which are commissioning by public health (local

authority), is not always well understood in healthcare

services� Availability and signposting of services is patchy�

There is an opportunity to make better use of available

services and to better embed them into clinical pathways�

There is a need to evaluate sustained change in physical

activity levels and to understand return on investment for

commissioners�

In order to maximise the use of available activity on

referral schemes and sport and exercise medicine expertise

it is recommended that commissioners ensure local

understanding of what is available, who should be referred

and how to go about doing so�

Suggested actions include:

• Stakeholderengagement,marketingand

communication about activity on referral schemes with

all healthcare professionals and provider organisations

- not just in primary care�

• Ensuringavailableservicesaresetuptoreceive

referrals from across the spectrum of healthcare

services/providers�

• Commissionsportandexercisemedicineservices,

specifically exercise medicine�

• Trainingtoensureunderstandingwhentoreferto

a network of sport and exercise medicine specialists

including patients with illness or injury preventing

physical activity�


5 Recommendations

5.2.5 Training curricula

Education training and support should be implemented

across the East Midlands to support these initiatives

including but not limited to:

• Medicalschoolcurricula

• Nursingcurricula

• Alliedhealthprofessionals’trainingcurricula

• Juniordoctorcontinuingprofessionaldevelopment

• GPvocationaltrainingscheme

There is a need to streamline and simplify existing advice

and resources to enable healthcare staff to respond to

patient need - what to advise patients to do and how to

accesssupport.Linkedtothisisanabsoluterequirementto

upskill the healthcare community to employ motivational

interviewing skills�

5.2.6 Evidence the benefits / return on

investment

Physical activity services delivering both prevention and

treatment of ill health should be contracted and managed

to ensure their value is evidenced� It is recommended that

servicesaremonitoredandprovidersrequiredtoevidence

performanceacrossthedimensionsofquality,cost,delivery,

safety and morale�

See examples on table 6


5 Recommendations

Quality Cost Delivery Safety Morale

QU

ALI

TATI

VE

Patient

feedback

Complaints

and

compliments

Patient

feedback

Description of

adverse patient

events

Patient

feedback

QU

AN

TITA

TIV

E

Individual

patient health

results (eg�

sedentariness

& associated

adverse health

parameters

- eg blood

pressure,

HBA1C)

Percentage

of patients

continuing

activity levels

post six months

Cost per

patient

Cost per

session

Fixed costs

Variable costs

Cost avoidance

(e�g� drugs

cost)

Waitinglists

Percentage

of patients

completing

programme

Percentage

of patient

referrals

accepted

Number of

adverse patient

events

Percentage

of patients

continuing

activity levels

post six months

Table 6 - Examples of measures


5 Recommendations

5.2.7 Physical activity as a treatment for

mental health

Whilstthereisagenerallackofwelldesignedandlarge

trials using clinical populations of people with mental

health problems, the largest trial with adults - the TREAD

trial(fundedbyHTAanpublishedinBMJ)questionedthe

valueofexercisefordepression.Subsequentreviewpapers

questionedtheconclusionsdrawn.Thereremainsaneed

for large scale, multi-centre trials in both adults and children

and young people with mental health problems�

It is accepted that engaging in exercise can have numerous

positive benefits on mental wellbeing and psychological

functioning both in children and young people� Specifically,

it has been reported that engaging in exercise can lead to

improvements in self-esteem and self-perception, mood,

sleep and insomnia and psychological stress� Exercise can

also lead to symptom improvement for people experiencing

mental health problems�

Studies have documented the effect of physical activity on

various mental health disorders� Exercise as a preventative

measure and a treatment for depression has been

increasingly researched in adult populations over the

previous three decades, with numerous studies reporting

positive and encouraging results� It has been established

that exercising, even at levels below those recommended

by the Chief Medical Officer, can be sufficient to elicit

reductions in depression�


5 Recommendations

5.2.8 Thinking differently

Commissioners are encouraged to consider alternative

approaches to directing patients to physical activity services�

Recognising the considerable pressure on GPs, it may be

possibletoengagepharmacists’support.Whenapatient

presents a prescription for hypertension for the first time

- for example, could a pharmacist make a judgement on

whether to swap their prescription for a “green” one?

Pharmacies could continue to monitor patient’s blood

pressure and receive payment for the prescription as they

would if providing drug therapy�

It should not just be the responsibility of primary care to

askquestionsofpatientsabouttheirlevelsofactivity:the

biggestcauseofliverdisease(cirrhosis)intheUKisobesity

(greater than alcohol and viral hepatitis combined)� Do

patients who see a physician get asked about activity levels

and do these professionals have access to referral schemes

for their patients?

5.3 The Clinical Senate recommends the

following be actively commissioned -

across health and social care

5.3.1 Education programme: Everybody active,

every day: (primary, secondary and tertiary

prevention)

Education programmes for all healthcare professionals to

enable provision of lifestyle advice to include physical activity

both as a preventative and as management for long term

conditions�


5 Recommendations

Motivational interviewing is an essential skill for health and

social care professionals to assist patients and clients to

develop positive habits�

5.3.2 Healthy workplace

All employers should consider how to create healthy

workplaces for their own staff in addition to provision of

therequirededucationandsupporttoensuretheyfeel

confident to make every contact count�

In the region there is an opportunity to link to the work

of the East Midlands Platform on Food, Physical Activity

and Health www�regionalplatform�org�uk.TheWorkplace

WellbeingCharterprovidesemployerswithaneasyand

clear guide on how to make workplaces a supporting and

productive environment www�wellbeingcharter�org�uk

WithintheNHSthereshouldbeafocusonaugmentingand

spreading areas of good practice in workplace wellness, with

a focus in return to work� A good example is Nottingham

UniversityHospitalswww�nuh�uk/healthandwellbeing

5.3.3 Review of existing service provision

Whilstitisrecognisedthatthereareexamplesofexcellent

services available within the East Midlands aimed at both

prevention and treatment of ill health we do not have

equitableprovisionacrosstheregion.Patientsoften

experience more than one health challenge and their needs

for support to access physical activity are likely to cut across

existing silo based provision� Consideration should be given

to co-morbidities and the development of symptom-based

services (rather than condition specific)�


5 Recommendations

It is recommended that commissioners seek to understand

the overall level of demand for both preventative and

treatment based physical activity services in their healthcare

community� Areas to consider might be

• whowouldbenefitfromphysicalactivity-preventative

and treatment focused?

• definepatientgroups

- primary prevention - by disease area, prevalence

and patient numbers

- current GP attendance by exercisers with a

problem preventing them from undertaking their

usual activities

- chronic medical problems that physical activity

would help - by disease area and prevalence and

patient numbers

- annual musculoskeletal injury numbers

- mental health

A review of existing provision should follow that takes in

all local provision - both directly commissioned services

and those contained within block contracts and disease

pathways to consider the benefits of re-commissioning

services on a symptom basis� It is felt that bringing pockets

of silo based activity together into larger services will enable

removal of multiple administrative efforts and increase

the percentage of time spent on patient facing delivery of

services�

Scope for greater innovation and partnership working

with commercial partners should be considered� For

example, providing physiotherapy services from a gym

might encourage people who have never been in such an

environment to increase their physical activity over and

above participation in therapy�


5 Recommendations

It is appreciated that some specialist services should remain

so - for example stroke rehabilitation and post myocardial

infarction cardiac rehabilitation�

5.3.4 Exercise medicine: (enhanced secondary

and tertiary prevention)

Commissioners are encouraged to support, develop, pilot

and evaluate exercise medicine services for those:

• wishing to become more physically active but with

medical and/or musculoskeletal issues preventing uptake

• needingphysicalactivityforthetreatmentofchronic

disease

• withrehabilitationneeds,includingreturntowork

There is an additional role for specialist sport and exercise

medicine services to provide support and leadership for the

delivery of wider physical activity in both prevention and

treatment�

The National Centre for Sport & Exercise Medicine (NCESEM)

can provide primary and intermediate care networking

opportunities�

Commissioned services should be embedded with local

authority run physical activity and lifestyle programmes�

The Faculty of Sport and Exercise Medicine offer the

following advice:

• Itisexpectedthatdifferentlocalitieswillchooseto

implement sport and exercise medicine services in

variable ways and over differing timescales according

to local needs�

• The development of sport and exercise medicine services

can be flexible according to local pressures and needs�


6.1 Chief Medical Officer Physical

Activity Guideline

For early years (under fives)

1� Physical activity should be encouraged from birth,

particularly through floor-based play and water-based

activities in safe environments�

2� Children of pre-school age who are capable of walking

unaided should be physically active daily for at least

180 minutes, spread throughout the day

3� All under fives should minimize the amount of time

spent being sedentary (being restrained or sitting) for

extended periods (except time spent sleeping)

These guidelines are relevant to all children under five,

irrespective of gender, race or socio-economic status, but

should be interpreted with consideration for physical and

mental capabilities�

For children and young people (five to 18 years)

1� All children and young people should engage in

moderate to vigorous intensity physical activity for at

least 60 minutes and up to several hours every day�

2� Vigorous intensity activities, including those that

strengthen muscle and bone, should be incorporated

at least three days a week�

3� All children and young people should minimize the

amount of time spent being sedentary (sitting) for

extended periods�

Based on evidence, the guidelines can be applied to disabled

children and young people, emphasising that they need

to be adjusted for each individual based on that person’s

exercise capacity and any special health issues or risks�

6 Appendices


6 Appendices

For adults:

1� Adults should aim to be active daily� Over a week,

activity should add up to at least 150 minutes of

moderate intensity activity in bouts of ten minutes or

more - one way to approach this is to do 30 minutes

on at least five days a week�

2� Alternatively, comparable benefits can be achieved

through 75 minutes vigorous intensity activity spread

across a week or a combination of moderate and

vigorous intensity activity

3� Adults should also undertake physical activity to

improve muscle strength on at least two days a week

4� All adults should minimize the amount of time spent

being sedentary (sitting) for extended periods�

Based on the evidence, the guidelines can be applied to

disabled adults, emphasising that they need to be adjusted

for each individual, based on that person’s exercise capacity

and any special health risks or risk issues�

For older adults (65 plus years)

1� Older adults who participate in any amount of

physical activity gain some health benefits, including

maintenance of good physical and cognitive function�

Some physical activity is better than none, and more

physical activity provides greater health benefits�

2� Older adults should aim to be active daily� Over a

week, activity should add up to at least 150 minutes of

moderate intensity activity in bouts of ten minutes or

more - one way to approach this is to do 30 minutes

on at least five days a week�

3� For those who are already regularly active at moderate

intensity, comparable benefits can be achieved through

75 minutes of vigorous intensity activity spread across

the week or a combination of moderate and vigorous

activity�


6 Appendices

4� Older adults should also undertake physical activity to

improve muscle strength on at least two days a week�

5� Older adults at risk of falls should incorporate physical

activity to improve balance and coordination on at

least two days a week�

6� All older adults should minimize the amount of time

spent being sedentary (sitting) for extended periods�

Based on the evidence, the guidelines can be applied to

disabled older adults emphasising that they need to be

adjusted for each individual based on that person’s exercise

capacity and any special health or risk issues�

6.2 Who is currently responsible for what?• Physicalactivityisnotmandatedinpublichealth

outcomes but health checks are

• Therearenoringfencedbudgetsforphysicalactivity

o Children’s services

Physical literacy is part of the health visitor offer

and early years foundation stage curriculum

Physical education curriculum in schools

School nurse role in picking up child obesity,

promoting positive health and making referral/

recommendation where risk identified

Sport England - activity targets including active

travel along with sports’ governing bodies

sport participation targets

Local authorities promote physical activity -

public health and prevention agenda

Local authority public health teams have

National Child Measurement Programme duty,

deliver weight management programmes and

lead healthy schools agenda


6 Appendices

Promoting parental responsibility and

messages to parents through all partners, and

national Change for Life campaigns

Primary care role in promoting good health

and identifying risk

o Adults

Individual responsibility - supported by

national campaigns to promote 150 minutes

of physical activity per week message

Workplacehealth-Localauthoritypublic

health teams working with employers to

promote workplace policies (active travel, cycle

to work, etc)

Sport England have sport and recreation

activity targets

Local authorities as part of weight

management/lifestyle services including

exercise referral

Primary care - promotion of good health for

healthy adults - Making Every Contact Count -

and health checks for target population

Primary care, management of long term

conditions - need better understanding of

physical activity as treatment/management

e.g.WalkingAwayfromDiabetesinLeicester

Secondary care - part of treatment pathways

e�g� cardiac and pulmonary rehab, falls

pathways, re-ablement, and part of discharge

advice with respect to regaining/maintaining

independence and ongoing rehabilitation post

care episode - include in care plans and share

with GP and social care teams

Social care, supporting independent living


6 Appendices

6.3 Examples of existing provisionThe following examples were made known to the author of

this report

6.3.1 Leicestershire and Rutland

• CountySportPartnerships-LeicestershireCounty

Council and Leicester-Shire & Rutland Sport, through

development of a countywide sport and physical

activity plan have developed a targeted approach

aimed at sectors of the community who currently do

little/no physical activity� The majority of the resources

focus on targeted individuals / groups or communities:

early years, inactive young people, people on low

income, supporting Leicestershire families, people with

disabilities, people with long term conditions, people

with continuing healthcare services, families, and

healthyweight.Eachlocalitywasrequiredtosubmita

'one stop sport and physical activity plan'�

o Over 2million attendances recorded at sessions

included in the sport & physical activity plans

from 2012-2014�

o A joined up local offer, that focuses on inactive

communities who can derive the greatest health

benefit�

o There has been a move to delivering more

targeted interventions with the focus on impact

rather than ‘numbers’�

o Development of an evidence based approach

supporting a local delivery model that offers:

Targeted physical activity programmes, age

and life stage appropriate, to a large and

dispersed population�

New targeted programmes, which can be

adapted for use with a wide range of age

groups and abilities�


6 Appendices

A community based delivery model that will

provide services in community venue�

A community empowering approach,

by training local community providers to

deliver the programme and encourage user

involvement to expand the programme within

specific user-groups, through a cascade model

of training�

Interventions based on multi agency identified

need and complimentary programmes of

delivery�

Planned action, integral to a local multi agency

approach to public health brief interventions

delivered by a workforce competent in

community development/based approaches

that focus on future sustainability and impact

from the start�

A planned promotional campaign to raise

awareness of the health and wider benefits of

sport and physical activity�

o A number of specific interventions delivered are

linked to support the prevention / management

of:

Mental health

Dementia

Long term conditions

Coronary heart disease

Cardiovascular disease

Healthy weight

Diabetes

Falls prevention

o Specific Referral based programmes include:

Exercise referral

Heartsmart


6 Appendices

Weightmanagementprogrammessuchas

LEAP & Flic

Get Healthy, Get Into Sport

• DESMOND-WalkingawayfromDiabetes

• Exercise(health)referralTier2-Commissioned

by Leicestershire County Council Public Health

Directorate.ProvidedbyNorthWestLeicestershire

District Council, Hinckley & Bosworth Borough Council,

Oadby&WigstonBoroughCouncil,Charnwood

District Council, Melton Borough Council, Harborough

District Council, Blaby District Council & Rutland

County Council� 12 week programme offering tailored

1-1 and/or monitored support and assessment by a

level 3 physical activity instructor� A growing range of

appropriate physical activity programmes are offered

to participants including gym based exercise, walking,

swimming, and cycling� All referrals must classed as

inactive*, be aged 16+ and exhibit at least one of the

following risk factors for coronary heart disease (CHD)

or metabolic syndrome :

o Smoking

o Family history of heart disease

o High cholesterol levels

o Obesity/overweight (BMI 25+)

o Hypertension (140/90 to 179/99mmHg)

o Controlled diabetes

o Have been diagnosed with osteopenia or

osteoporosis

o Mental illness /psychiatric disorders where

appropriate physical activity would be beneficial

e�g� depressive disorders or anxiety disorders�

o Locomotive and neurological disorders where

appropriate physical activity would be beneficial

o Controlled asthma


6 Appendices

o Chronic pulmonary disease (subject to

assessment by pulmonary rehabilitation specialist

orequivalent)

• “Heartsmart”cardiacrehabreferral(Tier3)-

Commissioned by Leicestershire County Council

PublicHealthDirectorate.ProvidedbyNorthWest

Leicestershire District Council, Hinckley & Bosworth

BoroughCouncil,Oadby&WigstonBoroughCouncil,

Charnwood District Council, Melton Borough Council,

Harborough District Council, Blaby District Council &

Rutland County Council� 12 week programme offering

tailored 1-1 and/or monitored support and assessment

by a level 4 physical activity instructor� A growing range

of appropriate physical activity programmes are offered

to participants including gym based exercise, walking,

swimming, and cycling� All referrals must classed as

inactive*, be aged 16+ and have had a recent cardiac

event or surgery (patients should be directed initially to

phase IV by GP/cardiac rehabilitation services)

• Fundamentalmovementskillsfor5-11yearolds-

Commissioned by Leicestershire County Council Public

Health Directorate� Provided by SAQ International

Ltd� A pilot programme for seven primary schools in

Leicestershire� The service aims to develop an early

identification and intervention programme for young

children with deficient fundamental movement skills

in order to raise their physical abilities to the expected

norm� Programmes work with pupils, teachers and

parents� Trained interns embedded into schools to

support the monitoring assessment and intervention

programmes with pupils, to support and train school

staff and parents, and intensively work with at risk

children�


6 Appendices

6.3.2 Northamptonshire

• NorthamptonshireCountyCouncil-20millionsteps

challenge September 2014

6.3.3 Derbyshire

• MansfieldDistrictCouncil-GetActive

• DerbyshireSport-TheActiveDerbyshirePlanincluding

The Maternal Healthy Lifestyles Programme

6.3.4 Nottinghamshire

• GetActiveMansfield(GPexercisereferral-local

authority run/providers)

• HealthyChange-areferralandsupportcentrewhich

offers ongoing over-the-phone support to citizens who

want to make changes to the way they live� They can

also arrange for people to attend one or more of the

services below for free�

• Motivate offers a free 12 week weight management

programme of exercise and nutritional advice aimed

at overweight men, delivered by Notts County FC

Football in the Community sports coaches�

• Active For Life(YMCA)offersafree12-weekexercise

and motivational support programme to support

people in becoming more active�

• Be Fit offers free gym use, fitness classes and swimming*

atJohnCarroll,Victoria,andSouthgladeLeisureCentres

between 10am-12pm and 1pm-3pm Monday to

Saturday, for city residents who receive certain benefits�

• Best Foot Forward offers free weekly short guided

health walks around various open spaces in the city�

• Ridewise (Cycling for Health) offers free cycle training

sessions and organised group rides for people in

Nottingham�


7.1 Literature review1. BattMEandTanjiJ.Thefutureofchronicdisease

managementandtheroleofSEMphysicians.ClinJ

Sports Med 2011 21(1)

2. WeilerR,FeldschreiberPandStamatakisE.

Medicolegal neglect: the case for physical activity

promotioninprimarycare.BrJSportsMed2011:

doi:10�1136/bjsm�2011�084186

3� Blair SN - Physical inactivity: the biggest public health

problem of the 21st century

4. Yates,Wilmot,Khunti,Biddle,Gorely,Davies-Stand

up for your health: Is it time to rethink the physical

activity paradigm?

5. UKhealthperformance:findingsoftheGlobal

Burden of Disease Study 2010 - Lancet

6. Cooney,G.M.,Dwan,K.,Greig,C.A.,Lawlor,D.A.,

Rimer,J.,Waugh,F.R.,McMurdo,M.andMead,G.

E� (2013) Exercise for depression� Cochrane Database

of Systematic Reviews 9 Cd004366�

7. Larun,L.,Nordheim,L.V.,Ekeland,E.,Hagen,K.

B� and Heian, F� (2006) Exercise in prevention and

treatment of anxiety and depression among children

and young people� Cochrane Database Of Systematic

Reviews (Online) (3) CD004691�

7 Referenced evidence base



7.2 Collation and summary of existing

professional and national guidelines1� Faculty for Sport and Exercise Medicine - A Fresh

Approach http://www�fsem�co�uk/media-resources/

publications�aspx

2� Public Health England Everybody active, every day

3� Moving More, Living More, The Physical Activity

Olympic and Paralympic Legacy for the Nation (2014)

4� Be Active, Be Healthy: A plan to get the nation

moving - HM Government

5� Change4Life - HM Government

6� Let’s Get Moving 2009 - HM Government

7� Royal College of Physicians - Exercise for Life� 2012

8� ACSM - Exercise is Medicine:

www�exerciseismedicine�org

9� FYSS-ProfessionalAssociationsforPhysicalActivity,

Sweden: Physical activity in the prevention and

treatment of disease� 2010

10� Tackling Physical Inactivity -A coordinated approach�

All-party commission on Physical Activity� 2014

11� Behaviour change: individual approaches� NICE public

health guidance 49 (2014)�

12� Physical activity: brief advice for adults in primary

care� NICE public health guidance 44 (2013)�

13� Walkingandcycling:localmeasurestopromote

walking and cycling as forms of travel or recreation�

NICE public heath guidance 41 (2012)�

14� Promoting physical activity for children and young

people� NICE public health guidance 17 (2009)�

15� Promoting physical activity in the workplace� NICE

public health guidance 13 (2008)�

16� Physical activity and the environment� NICE public

health guidance 8 (2008)�

http://www.fsem.co.uk/media-resources/publications.aspx

http://www.fsem.co.uk/media-resources/publications.aspx


https://www.gov.uk/government/publications/moving-more-living-more-olympic-and-paralympic-games-legacy

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_094359.pdf

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_094359.pdf

http://www.nhs.uk/change4life/Pages/change-for-life.aspx

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216262/dh_133101.pdf

https://www.rcplondon.ac.uk/sites/default/files/documents/exercise-for-life-final_0.pdf

http://www.fyss.se/wp-content/uploads/2011/02/fyss_2010_english.pdf



http://activitycommission.com/report-tackling-physical-inactivity-a-coordinated-approach/

https://www.nice.org.uk/Guidance/PH49











17� Behaviour change: the principles for effective

interventions� NICE public health guidance 6 (2007)

18� http://www�macmillan�org�uk/Cancerinformation/

Livingwithandaftercancer/Physicalactivity/

Physicalactivityandcancer/Benefits�aspx

19� http://www.macmillan.org.uk/Documents/AboutUs/

Commissioners/Physicalactivityevidencereview�pdf

20� http://www�macmillan�org�uk/Documents/

AboutUs/Health_professionals/

PhysicalActivityEvidenceBasedGuidance�pdf



http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Physicalactivity/Physicalactivityandcancer/Benefits.aspx



http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf

http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf

http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PhysicalActivityEvidenceBasedGuidance.pdf




The Clinical Senate would like to thank Senate Council and

Assembly members for their contribution to the preparation

of this advisory report�

Further thanks to the Physical Activity Panel -

Jo Spokes - Sports Development Manager - Leicestershire

and Rutland Sport (a County Sports Partnership (CSP) - Local

Authority provision of Sport and Physical Activity

Grace Hutchinson - Performance Info and Research Officer

- Leicestershire and Rutland Sport - providing statistical and

research support

Polly Todd - Manager of teams of health visitors and school

nurses - National Child Measurement Programme

Fiona Moor - Head of Dietetics - Derby Acute and

Community

Ben Anderson - Consultant in Public Health (Healthcare),

Public Health England Centre East Midlands

Jean Wong - GP Principal Pinfold Medical Practice

Loughborough, GPwSI Sports and Musculoskeletal Medicine,

Clinical Assistant Orthopaedics Leicester General Hospital,

International Health Rep RCGP Leicester Faculty

James Hopkinson - GP and Consultant in Sports Medicine

and CCG commissioning lead

Ann Goodwin - Consultant in Healthcare Public Health,

Public Health England Centre East Midlands

Sue Collington - Lead Occupational Health Nurse,

UniversityhospitalsofLeicesterNHSTrust

8 Acknowledgements


8 Acknowledgements

Anne Garland - Nurse Consultant in Psychological

Therapies, Clinical Lead Specialist Depression Service,

Nottinghamshire Healthcare NHS Trust

Meng Khaw - Public Health England’s Centre Director for

the East Midlands

Claire Porter - Specialist Nurse/Lead Nurse for Burns and

Plastic Surgery

Anne Willmott - Consultant Paediatrician and Paediatric

Gastroenterologist,UniversityHospitalsLeicester

Bernadette Armstrong - Extended Scope Physiotherapist,

Northamptonshire Healthcare Foundation Trust

Chaman Verma-EqualityandDiversityManager,Kettering

General Hospital

Tim Carter - Teaching and Research Associate (Mental

Health),UniversityofNottingham

Patrick Callaghan - Professor of Mental Health Nursing,

UniversityofNottingham

Mike Sandys – Director of Public Health, Leicestershire

County Council

Specific thanks to Ben Anderson, Consultant in Public Health

(Healthcare), Public Health England Centre East Midlands

andtoDrFu-MengKhaw.

Further thanks to both Professor Melanie Davies and

ProfessorKamleshKhuntiandteamsattheNIHRLeicester-

Loughborough Diet, Lifestyle and Physical Activity

BiomedicalResearchUnitfortheirexpertiseandinput.

SKYLINE. GRAPHIC DESIGN www�skylinedesign�org�uk

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